Module 11.2 - Benign Prostatic Hyperplasia

Question 1

What is BPH?

Answer 1

Enlargement of the prostate gland, specifically within the prostatic transition zone, commonly occurring as men age. Symptomatic patients may benefit from medical or surgical treatment.

Question 2

What are the clinical manifestations associated with BPH?

Answer 2

Obstructionand increased smooth muscle tone and resistance within the enlarged gland lead to symptoms such as:

• Hesitancy, straining, starting and stopping, dribbling, retention, decreased force and caliber of stream, sensation of incomplete bladder emptying, and double voiding (urinating again within 2 hours)

Irritative symptoms associated with bladder dysfunction:

• symptoms such as frequency, dysuria, urgency, nocturia, and incontinence

Question 3

What are some physical examination findings associated with BPH?

Answer 3

• Digital Rectal Examination (DRE) - enlarged prostate, smooth and rubbery; size does NOT correlate to degree of symptoms or with degree of obstruction;
• If focal nodules or extreme hardness present on DRE, may represent malignancy, refer to Urologist for radiologic imaging and biopsy
• Palpable bladder consistent with urinary retention

Question 4

What are some laboratory/diagnostic findings associated with BPH?

Answer 4

A. Urinalysis: pyuria suggests infection; hematuria may be sign of malignancy

B. Urine C&S – to rule out infection

C. BUN/Creatinine – to assess for renal insufficiency

D. Prostatic Specific Antigen (PSA) – optional

• Normal 2-4 ng/ml (this does not guarantee a patient does not have cancer)
• Elevated > 4 ng/ml ( can be from BPH or malignancy or prostatitis/UTI)

E. Transrectal ultrasound – obtained with a palpable nodule or elevated PSA

Question 5

How do you manage a patient with mild BPH symptoms?

Answer 5

The decision to treat BPH balances the severity of the patient’s quality of life symptoms with potential side effects of therapy.

• Watchful waiting
• Avoid medications that can worsen symptoms: examples include a decongestant, diuretics, sympathomimetic, anticholinergics, bowel antispasmodics, tricyclic antidepressants, opiates and antipsychotics (decrease bladder muscle contraction increasing urinary retention).

Question 6

How do you manage a patient with mild to moderate BPH symptoms?

Answer 6

• Alpha blockers- the preferred agents for BPH; relax muscle fibers in prostate gland, capsule and internal urethral sphincter
• Examples of Alpha blockers: Terazosin, Prazosin, Doxazosin
• Adverse events: Hypotension and dizziness
• Alpha 1a blockers: (less hypotensive side effects) examples: tamsulosin (Flomax), alfuzosin, silodosin (Of Note: Tamsulosin exhibits selectivity for alpha 1 receptors in the human prostate which is why it causes less hypotensive side effects)

Question 7

How is finasteride used in BPH?

Answer 7

• Blocks conversion of testosterone to dihydrotestosterone
• Works on epithelial component of prostate, resulting in decrease in size of gland and improvement of symptoms
• 6 months of therapy is required for most beneficial effect

Question 8

How do you manage a patient with severe BPH symptoms?

Answer 8

• Surgery may be warranted – dependent upon severity of symptoms
• Indications: recurrent urinary tract infections, bladder stones , persistent obstructive urinary symptoms

Types of surgery:

• Transurethral resection of the prostate (TURP)
• Low Mortality (1%); Moderate Morbidity (18%)
• Retrograde ejaculation common post TURP
• Complications: bladder neck contracture, urethral stricture, incontinence
• Open simple prostatectomy
• Transurethral incision of the prostate (TUIP)

Question 9

Describe the physiologic changes to the prostate related to aging

Answer 9

Physiologic Changes Related to Age

• Decreased renal mass, blood flow and GFR (lose 10% per decade after age 30)
• Renal elimination of most medications
• Reduction in bladder elasticity, tone and capacity
• Increased post void residual and nocturnal urine production
• Male reproductive changes:
  
  • Prostate enlargement
  • Decreased testosterone levels leads to increased estrogen : androgen ratio
  • Increase in gynecomastia
  • Decrease in sperm motility

Sexual function

• Slowed arousal time to achieve erection
• Erection less firm, shorter lasting
• Delayed ejaculation and decreased forcefulness of ejaculate
• Longer interval to achieving subsequent erection

Prostate

• By 40 years of age, there is hypertrophy of glandular tissue. This is stimulated by dihydrotestosterone